Intake - Adolescent (ages 12 - 17)Please complete prior to our first session. ** This form is not "secure". Keep that in mind when completing it and prior to sending it to me. I cannot guarantee the security of the internet. This form is just as secure as sending any email over the internet. You can choose to either complete it in its entirety, complete a portion of it and "submit" it to me or we can complete it together in session. Any information you send me in advance is helpful.

* Indicates required field

Legal Name of Youth *

First

Last

Nick Name *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number of Parent *

Name of Parent of this phone # *

Can a message be left at this phone #? *

Email of Parent *

Birth date of Youth *

Youth lives with *

Current Age of Youth *

Youth's parents are *

Parent #1 Name *

First

Last

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Can a message be left at this phone #? *

This parent is *

This parent is employed outside the home *

Parent #2 Name *

First

Last

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Can a message be left at this phone #? *

This parent is *

This parent is employed outside the home *

Add'l Caregiver Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Relationship to Youth *

Does caregiver live with youth? *

Why are you seeking counseling for the youth? *

Has the youth already been in counseling? *

How has the family tried to resolve the youth's issues? *

If yes, please give the counselor's name and city located. *

Sibling Name *

Sibling Name *

Sibling Name *

Sibling Name *

Sibling Age *

Sibling Gender *

Sibling Age *

Sibling Gender *

Sibling Age *

Sibling Gender *

Sibling Age *

Sibling Gender *

Does this sibling live at home with youth? *

Does this sibling live at home with youth? *

Does this sibling live at home with youth? *

Does this sibling live at home with youth? *

Behaviors / Symptoms

Youth struggles with: *

DistractibilityHyperactivitySadness/DepressionSibling/Peer ConflictConflict with ParentsFear Away From Home